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Although care has been taken in preparing the information supplied by the BSA,
the BSA does not and cannot guarantee the interpretation and application of it.
The BSA cannot be held responsible for any errors or omissions, and the BSA
accepts no liability whatsoever for any loss or damage howsoever arising. This
document supersedes any previous recommended procedure by the BSA and
stands until superseded or withdrawn by the BSA.
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Audiology.
2 © BSA 2010
Recommended procedure British Society of Audiology
Caloric test 2010
Contents
1. Introduction ....................................................................................................5
2. Scope ............................................................................................................6
5.1.2. Calibration...........................................................................12
3 © BSA 2010
Recommended procedure British Society of Audiology
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5.2.2. Calibration...........................................................................13
7. References ..................................................................................................18
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1. Introduction
The bi-thermal caloric test was introduced into clinical practice in the early 1940s,
mainly as a result of the development work of Fitzgerald and Hallpike (1942).
Evaluation of the induced nystagmus was based upon the observer timing the
duration of the response. Later recording techniques such as electro-
nystagmography allowed the responses to be quantified in terms of the slow
phase velocity and duration of nystagmus eye movements. Today a variety of
techniques are in use in clinics throughout the United Kingdom.
Sections 2, 3, 4 and 6 of this document cover general issues that apply to all
caloric testing. Section 5 describes the specific recording techniques used in eye
movement assessments.
The Steering Committee would like to acknowledge the advice received from a
range of professionals (see Appendix A), as well as the wider membership of the
BSA who were invited to provide comments and feedback on earlier draft
editions. The document was developed in accordance with BSA Procedure for
Processing Documents (2003).
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Recommended procedure British Society of Audiology
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2. Scope
The results of the caloric test, in terms of the responses to four stimuli, are used
to obtain a measure of canal paresis (also known as unilateral weakness) and
directional preponderance. Canal paresis expresses a weakness in the induced
nystagmus following caloric stimulation from one ear as compared to those
obtained from the opposite ear. A directional preponderance indicates that the
nystagmus response is greater in one direction as compared to the other.
The document is primarily written as a recommend procedure for carrying out the
caloric test in adults. It is acknowledged that the caloric test is used to investigate
vestibular function in babies and young children. However, it is beyond the scope
of this document to describe the test modifications necessary and interpretation
of results.
It is also beyond the scope of this document to describe and discuss the
limitations of the caloric test. Although it is known to “reliably and accurately
differentiate between normal vestibular output and abnormally reduced or
increased output”, it establishes this for only the lateral semicircular canals and is
equivalent to a low frequency sinusoidal harmonic acceleration rotation test
(Baloh et al, 1989; Zapala et al, 2008).
3.1. Hygiene
Check that the irrigation system is clean and operating correctly. If water tanks
are used, these should ideally be cleaned and re-filled at least weekly.
Use decontaminated irrigator nozzles for each patient (Baguley et al, 1991).
It is recommended that the department should comply with local infection control
policy where this is indicated.
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Table 1
Stimulus parameters1
Temperature: Temperature:
Flow rate
‘cold’ ‘warm’
Water 30 °C 0.4 °C 44 °C 0.4 °C 250 ml 10 ml in 30 s
Air 24 °C 0.4 °C 50 °C 0.4 °C 8 l 0.4 l in 60 s
This would allow the tester to consider application of the mono-thermal caloric
screening test (See Appendix C).
1
Lightfoot (personal communication 2010) reports that the effectiveness of the stimulus in air calorics depends not only
on the flow rate but also the speed of the column of air and therefore crucially on the diameter of the tip delivery system.
Even if the irrigator provides the stimulus parameters described, users should collect their own normal limits and be aware
of this dependency.
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The caloric response should be measured in terms of either the maximum slow-
phase velocity (SPV) of the nystagmus in degrees per second, ° s-1, (see
Section 5) or the duration of the nystagmus in seconds (see Appendix D).
The four responses are represented in this document by the following notations:
These statistics should not be used with patients that have unilateral or bilateral
tympanic membrane perforations (air or closed loop water caloric test) or
unilateral middle ear pathology. This is because there is considerable potential
for asymmetrical heat transfer from the ear canal to the semi-circular canal
between the two sides. In such cases, responses indicate only the existence of
semi-circular canal function.
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If a caloric nystagmus is not induced and technical reasons have been ruled out,
irrigation at temperatures below the minimum temperature indicated in 3.2
(Table I) may be considered. A suggested procedure is given in Appendix B.
4. Patient preparation
This section is related to actions taken prior to starting the caloric test and
ensuring that the patient is prepared adequately to undertake the test.
Only patients with a written referral by medical staff should undergo this test.
Advice about stopping medication (e.g. vestibular sedatives) should be given by
the referring physician during the pre-test consultation. Ideally the physician
should advise the patient to stop relevant medication at least 48 hours before the
test. Patients should be advised not to consume alcohol for 48 hours before
testing (Jacobson et al, 1993). Staff responsible for carrying out the caloric test
should check that the patient has adhered to this advice.
Check travel arrangements and ensure that patient is aware that they will be
advised not to drive immediately following the test.
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4.4. Contraindications
It is usually inappropriate to conduct the caloric test if any of the following are
present:
The next list shows the second level of contraindications / special precautions,
which should be checked for compliance at the time of the appointment by the
testier as well as by the referring physician and which also may contraindicate
performance of the caloric test:
● Otitis externa
2
Recent work by Kasbekar et al (2010) suggests that heart rate and mean arterial pressure are not significantly altered
by the caloric test. Although this is only preliminary work and based on data from 18 patients, it should allow the
researchers to study the effects on patients with stable cardiovascular disease. This may reduce the perceived risk of the
caloric test with these types of patients.
3
It is not clear what constitutes unsafe peak middle-ear compliance on tympanometry for water calorics. A hyper-mobile
tympanic membrane has been defined as a peak compliance of greater than 1.8 ml although it may still be appropriate in
some cases to proceed with water calorics with a peak compliance of 2.8 ml. If in doubt, medical advice should be sought.
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● Patients with mastoid cavities may be considered for air calorics, but
interpretation should be carried out with caution.
Staff performing the test should be aware of these contraindications and the
specific relevant specialist should be contacted for advice on individual patients.
Perform otoscopy (BSA, 2010) and tympanometry (BSA, 1992) to check the
condition of the external ear and tympanic membrane (e.g. look for signs of
atrophic tympanic membrane) before the start of the caloric test (and after each
irrigation).
Make the patient as comfortable and relaxed as possible. Explain to the patient
that the test involves warming and cooling the external ear canal and that this
may or may not result in dizziness lasting about two minutes. It may be
reassuring to explain that any dizziness experienced is a normal reaction and
that the test is not intended to provoke an episode of their own dizziness.
Obtain verbal consent to proceed.
The horizontal semi-circular canal should be brought into the vertical plane. As a
first approximation, this can be achieved by having the subject supine with either
his/her head or head and back inclined at 30 degrees to the horizontal (Coats
and Smith, 1967). The angle is correct when the external auditory canals and the
outer canthi are aligned vertically (Blanks et al, 1975).
Several methods for recording eye movements are available, each with its own
advantages and disadvantages. It is recommended that the following methods
are available, if resources allow: measurement of the corneo-retinal potential
using electrodes (electro-nystagmography, ENG) and/or direct measurement of
movements of the pupils using infra-red video goggles (video-nystagmography,
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VNG). It is recommended that VNG is used in preference and that ENG is used
only when VNG is technically difficult.
The direct observation method has not been removed completely from this
recommended procedure and may now be found in Appendix D, which should
now reflect its historical rather than current importance. It also acknowledges the
fact that there may be occasions when it is the only feasible method available.
Place the goggles containing the video cameras on the patient’s face so that they
are comfortable. Adjust the position of the goggles and/or the cameras to achieve
a clear view of the pupils of the eyes even if the patient looks to the extremes of
gaze. If the patient has any obvious eye abnormality (such as a prosthetic eye,
squint / strabismus, dysconjugate eye movement) then monocular recording
should be considered, covering the weaker or problem eye with an eye patch
when appropriate to do so. Many VNG systems’ abilities to correctly identify the
pupil are disrupted if eye make-up such as mascara is used. Appropriate
instructions about not using make-up should be included in any appointment
letter.
5.1.2. Calibration
Calibration of eye movements should be performed in a dimly lit room and before
the first irrigation. It is generally unnecessary to carry out further calibration,
unless the cameras are moved within the goggles or if the goggles are removed
or repositioned. Follow the procedure recommended by the manufacturer for
positioning the patient relative to the light bar and for performing the eye
calibration.
The tester should ensure that a clear view of the eyes is maintained throughout
the caloric test, as the eye tracking software requires this.
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Using mildly abrasive gel, carefully rub the skin prior to electrode placement
(forehead, near the right and left exterior canthi). When the patient is connected
and disconnected from the equipment, the ground lead should be connected first
and disconnected last. With the leads connected to the recording equipment, eye
movement to the right produces an upward deflection of the trace and vice versa.
The two horizontal channel electrodes are placed such that they lie on an
imaginary line passing through the patient’s pupils when looking straight ahead.
They should be as close to the outer canthi as possible without restricting the
patient’s comfort or ability to blink. If the patient has any obvious eye abnormality
(such as a prosthetic eye or squint etc.) that may affect the ENG, then an altered
electrode placement should be considered such as monocular recording of the
better eye.
5.2.2. Calibration
For other systems, two calibration points should be placed in the horizontal plane
symmetrically in front of the patient at a distance such that they subtend an angle
of 20 degrees at the patient’s head. Instruct the patient to gaze alternately
between the right and left calibration points and adjust the amplifier gain to
produce a trace deflection of 20 mm ( 1 mm). In addition to the outer calibration
points, a marker defining the straight-ahead position should be provided.
For paper chart recorders a paper speed of 10 mm s-1 should be used.
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Note that if recording eye movements during the caloric test with eyes closed and
if Bell’s phenomenon (elevation of the eyes in the orbit) is evident and
compromising the recording with eye closure, then unlit Frenzel glasses can be
used with eyes open in a darkened room to eliminate visual cues (Baloh et al,
1977).
The first part of this section describes the process of executing the caloric
irrigation; the latter stages describe the measurement and analysis of eye
movement generated by the stimulus.
6.1.2. Before the first irrigation only, and with the patient in the caloric test position,
check for spontaneous nystagmus with and without visual fixation. The patient
should be instructed just as they will be during the recording phase of the test.
They should be instructed to gaze ahead, visual fixation removed, and to perform
a mental task that will minimise suppression of any nystagmus. Suitable mental
tasks include simple conversation, asking the patient to describe a room in their
house or asking him/her to perform mental arithmetic. It is important that the
tester maintains a consistent level of the patient’s alertness throughout the
recording periods of the test (Kileny et al, 1980). It may be necessary to adjust
any mental alerting task required to reduce blinks and other artefacts in order
that a clear trace is obtained. For example, occasionally the extent of caloric-
induced nystagmus is attenuated or even abolished if the patient’s eyes are
deviated to the extreme of lateral gaze. If this is apparent from inspection of the
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eye image during recording, the patient should be given an immediate instruction
that results in a return of their gaze to a more central direction. It is important to
consider that sometimes the patient may think they are looking ahead and so to
achieve a more central gaze direction, they should be instructed to “look slightly
to the left (or right)”.
6.1.4. Examine the ears again prior to irrigation. Demonstrate the stimulus temperature
to the patient by, for example, directing a small amount of the water/air to the
pinna.
6.1.5. Stimulate the selected ear for the specified period (water, 30 s; air, 60 s).
6.1.6. Direct the stream of water/air straight down the external ear canal to achieve a
good irrigation of the canal and tympanic membrane. Care should be taken with
the irrigator nozzle to avoid injury to the ear. In particular, during the irrigation it is
vital that the ear canal is not occluded by the nozzle and thus pressurised.
The irrigation system must be such that the insertion depth of the nozzle into the
ear canal is limited and that the tip of the nozzle cannot reach the tympanic
membrane. For water irrigation, the patient’s head should be slightly rotated in
order to ensure that the external canal is horizontal, allowing air in the canal to
escape as it is displaced by the water, thus preventing a pocket of air from
remaining in the canal and invalidating the calibration of the delivered thermal
stimulus. Following water irrigation the patient’s head should be gently returned
to a central alignment (it should be noted that this movement may induce one or
two beats of nystagmus, which should be discounted when analysing the results;
this occurs long before the normal peak in caloric induced nystagmus).
6.1.7. Recording, visual fixation removal and mental alerting can start either at the
beginning or end of the irrigation.
6.1.8. The same procedure should be applied for each irrigation (including calibration if
using ENG).
6.2.1. Observe the induced nystagmus in the eye movement trace without fixation as it
is recorded. Verify that it is regular and in the expected direction. Warm
irrigations would be expected to induce a nystagmus beating towards the
irrigated ear. Cool irrigations would be expected to induce a nystagmus beating
away from the irrigated ear; following the convention that nystagmus is described
in terms of the direction of the fast component.
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6.2.2. Soon after the response has passed through the period of maximum activity,
instruct the patient to fixate on a central target. After approximately 5 to 10 s
remove fixation again and continue recording for at least a further five seconds.
6.2.3. The total recording time, following cessation of irrigation, should be at least 60 s.
6.2.4. After the period of recording check the quality of the irrigation using an otoscope
to look for a ‘tympanic flush’. The presence of a tympanic flush confirms a good
irrigation (the converse is not necessarily true). This applies to warm irrigations
only.
6.2.5. Allow a minimum of seven minutes4 between the start of one irrigation and the
start of the next irrigation in order to ensure that the results of one test do not
affect the next. In cases where the patient is nauseous or produces evidence of
caloric nystagmus at the end of this period (that cannot be accounted for from
any spontaneous nystagmus measured as per Section 6.1.2), a further delay
may be warranted (Beattie and Koester 1992).
6.2.6. Between irrigations, calculate the average slow-phase velocity of the nystagmus
for the period of maximum response. Also calculate the visual fixation index
(VFI). (NB It is sufficient that the test for VFI be carried out for two irrigations
only, one for each direction of nystagmus.) See Section 6.3.4.
6.2.7. If there are serious doubts about the effectiveness of any irrigation, (e.g. lack of
tympanic flush after warm irrigation, insufficient mental alerting causing reduction
or suppression of nystagmus, or if one response is much weaker than the other
three) the suspect irrigation should be repeated after the four standard irrigations.
6.3.1. For automatic computerised eye movement measurement systems, verify that
nystagmus has been correctly identified by examining the trace and editing
where necessary. Check that the peak response has been correctly identified if
this is done automatically and adjust if necessary.
4
There is some evidence to suggest that the minimum period can be as little as 3 minutes or
much longer. However, the most recent research suggests that a compromise figure of 7 minutes
is employed.
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6.3.3. Most computerised systems will calculate canal paresis and directional
preponderance values automatically. Canal paresis (CP) and directional
preponderance (DP) may also be calculated using the expressions given in
Section 3.4 and users should be familiar with this method for verification
purposes and/or if using a non-computerised system.
2V2
Visual fixation index 100%
V1 V 3
6.4.1. It is recommended that individual laboratories collect their own data on what
constitutes the normal range of caloric response particularly if the parameters of
the caloric stimuli differ from those given in Section 3.2 (Jacobson et al, 1993)
since it can be diagnostically useful to define an abnormally low or a hyperactive
response as well as canal paresis and directional preponderance.
6.4.2. For air calorics it is recommended that normal limits be established even if the
stimuli parameters in Table I are adhered to (Lightfoot 2010).
6.4.3. Canal paresis and directional preponderance are normally distributed variables
and normal interpretive criteria should be based on mean ± 1.96 standard
deviations (note that mean should be approximately zero). Alternatively, if
normative data are not available, the normal limits of both canal paresis and
directional preponderance may be taken as 20 % (Jacobson et al, 1993).
6.4.4. When establishing normative limits for SPV from individual irrigations a different
approach is needed, as these variables have highly skewed distributions.
Although 8 ° s-1 represents the lower 95 % confidence limit for median of all four
irrigations, the 95 % confidence limits for individual irrigations are typically 5 ° s-1
and 57 ° s-1 (Lightfoot, 2004, and personal communication, 2007) with the warm
irrigations often resulting in somewhat stronger nystagmus than the cool. The
“total eye speed” of the maximum slow component velocity for all four irrigations
may be calculated, as suggested by Zapala et al, 2008 and this figure used to
infer either bilateral vestibular impairment (hypo-function) or hyper-function.
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6.5.1. When reporting the CP, the statement should refer to the weaker ear (but not
necessarily the one with the lesion). When reporting the DP, the statement
should refer to the direction of the fastest beating nystagmus generated.
6.5.2. In patients where the maximum SPV for all four irrigation is ≤ 5 ° s-1, the
calculation of CP and DP is likely to be misleading, as the absolute values are
similar to the possible systematic errors with this technique. [For example, if the
SPV values were LW = 2 ° s-1, RW = 3 ° s-1, LC = 2 ° s-1, RW = 4 ° s-1, this would
give a CP of 27 % of the left ear, whereas these figures either suggest function
from both ears is impaired (or alternatively poor irrigations or the patient
suppressing the response).]
6.5.4. There is no general agreement as to the normal limits for the visual fixation
index. For normal individuals and patients with peripheral vestibular disease, the
visual fixation index (VFI) is usually less than 50 %. If this value is exceeded,
central pathology might be suspected (Alpert, 1974; Takemori, 1977; Katsarkas
and Kirkham, 1982).
6.5.5. If there is a complete or almost complete abolition of the nystagmus with fixation,
calculation of the VFI is unnecessary. Also, unless there is a clear enhancement
of nystagmus during the period of fixation, the index has little diagnostic value
where the nystagmus in the absence of fixation is weak. It is important to
consider the patient’s visual acuity when interpreting the VFI.
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References
Baloh RW, Sills AW, Solingen L, Honrubia V. Caloric testing. 1. Effect of different
conditions of ocular fixation. Ann Otol Rhinol Laryngol Suppl 1977;86:1-6.
Beattie RC, Koester CK. Effects on interstimulus interval on slow phase velocity
to ipsilateral warm air caloric stimulation in normal subjects. J Am Acad Audiol
1992;3:297-302.
Blanks RHI, Curthoys IS, Markham CH. Planar relationships of the semicircular
canals in man. Acta Otolaryngol 1975; 80:185-196.
Coats AC, Smith SY. Body position and the intensity of caloric nystagmus. Acta
Otolaryngol 1967;63:515-532.
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Lightfoot GR. The origin of order effects in the results of the bi-thermal caloric
test. Int J Audiol 2004; 43:276-282.
Zapala DA, Olsholt KF, Lundy LB 2008. A comparison of water and air caloric
responses and their ability to distinguish between patients with normal and
impaired ears. Ear Hear 2008;29:585-600.
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With thanks to the following professionals who were consulted and who provided
advice:
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1. Place several ice cubes into a cup of chilled water and mix.
2. Measure the water temperature with a clinical thermometer and note the
temperature achieved.
3. Put a 2 ml syringe in the iced water, drawing in and expelling the water a few
times so that it reaches the correct temperature.
4. Perform otoscopy on the test ear. Incline patient’s head to one side to an
extent that is just sufficient to ensure that the test ear auditory canal runs
slightly downward from the horizontal so that water will not immediately run
out of the auditory canal. Place an absorbent tissue below the ear to be
irrigated - there is no need to catch the water in a bowl, the tissue will absorb
it.
6. Instruct the patient to maintain their head position during recording to ensure
that the water does not immediately drain out of the canal. Alternatively, after
a fixed period (e.g. 20 s) return the patient’s head to a central alignment
immediately prior to the removal of visual fixation.
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3. Time the duration of the nystagmus. Timing starts at the beginning of the
irrigation and ends at the last observable beat of the induced nystagmus (the
‘end-point’). Note the direction of the nystagmus and any significant
irregularity of the response.
4. At the end-point, switch the room lights off. Nystagmus is now likely to recur
as a result of the removal of visual suppression. Observe this nystagmus
using an infrared viewer or Frenzel glasses and time its duration (still
continuing from start of irrigation). Observe for the end point.
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